After one suicide attack, came another, then another. Trauma upon trauma. There are specific psycho-
emotional consequences, often submerged, neglected, or denied, resulting from suicide bombings and
conflict. What has been the experience of Israeli civilians? Practical coping approaches and mechanisms
have developed rapidly, but what about psycho-emotional coping skills? What wounds of the mind do they sustain, and what do they do about them? This chapter looks at the nature of trauma, and what it means to
individuals and communities. Included are testimonies of survivors, terror victim organizations, and those
dealing with traumatized primary responders and front-line health personnel. It looks at the meaning of post
traumatic stress disorder, effects of trauma on children, bereavement, the need for concerted strategies for
trauma-exposed populations, and how Israel's painful experiences are already being shared internationally.

The word 'pigua' is a Hebrew word used to describe a suicide bombing, but it cannot be adequately
translated. It comes from the same root as 'wound' (as in hurt, break, tear, pierce,
shatter). The word "trauma' originates from the Greek source meaning 'to wound'. Do civilians exposed to successive traumas build up
some kind of immunity and increase their ability to cope with it? Does successive exposure to trauma reduce
ability to cope?

Experiencing compounded stress at short intervals without any time and ability to regroup
and recover from the last episode can be psychologically devastating. "The imagery of terroristic violence
can become an unconscious organizing principle, determining how people see the world and how they
choose to act. Some would develop a militaristic coping strategy, tinted with paranoid suspicions that may
precipitate a new round of violence...terrorism imposes a threat to our value system, damaging the ability to
trust others and the assumption of living in a relatively safe world.' (Ayalon O, 2005)

"The main feature of trauma is rupture – it ruptures continuity in time, in relations and attachments, in perceptions of self and
others, in basic assumptions about the world, in future expectations, and above all, it ruptures the fabric of
meaning" (Gordon & Wraith 1993).

Conventional war is usually limited in time, scope and its geographical area, usually comes to an end, and is
followed by a period of relative tranquility – until the next time. Terrorism is a continuous, ever -present
threat, which has no time-scale, and is not confined to any specific area. It can occur inside the 'green line' or
beyond, and take the form of shooting, suicide attacks and car bombs. Even seemingly innocuous objects,
such as beer cans, watermelons or a neighbor's car in which terrorists have planted explosives, are potential
dangers as Israel experience has indicated . It can be harder for populations to cope with terrorism than
conventional war because there is no clearly defined area of danger- it can happen anywhere at any time, and
because in situations like the current violence, there is no defined end in sight. The information below
analyzes the difference between a terror attack and other types of trauma.

"Someone looks you in the eyes — then blows you up;
it shatters basic human assumptions."

"A terror attack is different from a traffic accident, which can also be sudden, unexpected,
devastating. The trauma of terror attacks is known to be more severe than the natural disasters such
as earthquakes and floods. Are there differences in the reactions to different types of terror attacks,
such as the reaction to drive-by shootings as opposed to suicide bombings? Civilians who are killed
in places like cafes and discos are slaughtered in what is supposed to be a comfort zone, which has
become a battleground.

Some basic human assumptions may be shattered when "someone looks you
in the eye – then blows you up", or when there are media images of people dancing in the street in
jubilation, holding up the limbs of our dead in their hands. People can't believe someone they don't
know would blow up the bus they are sitting in (or the train as in Madrid). Such acts challenge and
shatter ordinary assumptions making it hard to re-build assumptions about people.

The international media often practices role reversal as if the victims and wounded are themselves to
blame, especially if they are living in the 'territories'. Video clips of women bombers asserting their
desire to be shahids (martyrs) make Israeli civilians wonder what was going on in their minds. What
went wrong to cause them to do this? Assertions that deprivations are a root cause of suicide bombing
are disputed. Many of the bombers have come from professional, educated, employed and even
privileged backgrounds.

In Israel public recognition often follows a terror attack. There is a lot of public goodwill towards
terror victims. People experience a sense of shared fate and identity, as if relatives have been killed or
injured, as if all citizens are part of a single family. The direct victims may experience a wide range of
responses from others, such as support and heart-warming gestures from strangers, as well as
intrusion on their privacy, or avoidance. Many feel abandoned when they are replaced in the
headlines by the victims of more recent terror attacks.

There is some expectation on the part of survivors and families of victims that they will be helped and
in some way compensated, yet they may also feel a tinge of guilt when they receive financial help
because their loss has led to things being 'a bit better than it was before'. They feel a lot of anger that
is sometimes even directed at the Social Services and Social Security systems trying to help them, as
well as at terror attacks and terrorists.

Civilians also have to cope with regrets: "Unfortunately I got on a bus later than usual (which blew
up)." People also reflect on what could have been omens of disaster: "I felt that something was going
to happen that day." "I made an extra cell-phone call to my daughter."

There may also be cultural differences in how different sections of the Israeli population react. For
example, some people may feel less inclined to seek help, even when they need it. Physical injury can
lead to neglect of psychological damage, especially if someone is hospitalized for a long time and
there are numerous surgical and medical interventions that may themselves be traumatizing. The
needs of siblings can also be overlooked, if a brother or sister is killed in a suicide bombing.
Professional care-givers and social workers may experience the need to do a balancing act between
their regular case load of work and special crises. In order to do their work properly when a crisis
occurs, people must act automatically and be task-oriented and self-regulated. All their energies are
taken up, perhaps to a certain degree at the expense of ordinary care and prevention. Ordinary
matters almost become trivialized. Problems such as bed-wetting assume different proportions when
compared to a wounded and traumatized individual who has lost several family members in a bus
bombing. Professionals and associated workers often work at high energy levels. They need time to
stabilize their own physical and psychological strengths.

Most people feel some degree of trauma, even if they think they are not traumatized. For example,
when an Israeli goes abroad he/she may feel strange entering a foreign shopping mall, where there is
no security check.

Basically, terror has to do with facing questions of identity, of belonging. It challenges us all to be in
contact with feeling who we are, and where and to whom we belong."

Sources; Interview 13 June 2004 with E. P. Lecturer in Postgraduate Family Therapy
and School Counseling, Ranaana

"When a terrorist attack hits direct victims, an immeasurable number of people are caught up in the
traumatic ripple effects, forming ever widening 'circles of vulnerability' (Ayalon 2005). This includes
families who lost dear ones, friends, peers, primary responders, eyewitnesses, medical staff, social workers,
teachers, psychologists.

There is also the concept of 'rings of wounding'." They work the way an atom bomb
spreads. Picture a bull's eye. At its center is ground zero. This is where the blast goes off, people eating a
pizza, having a cup of coffee, waiting in line, riding a bus, going dancing, are destroyed. Then, within a
larger radius, people are wounded critically, moderately, lightly. The third ring of destruction is less acute,
'only' shock and blast injuries. Then there are those who actually hear the blast, whose hearts stop and knees
go weak, as they experience the thunder of the explosion. They are the ones who were on the spot only a
minute ago, right next door, or just down the street. They are the ones who just cannot get the sound of the
blast out of their heads. The fifth ring of pain and devastation encompasses families and friends – those who
know/knew the people killed, wounded and maimed in any of the prior circles. And then, in the sixth ring
there are those who were there, in that very spot, yesterday, last week, last month, last year. They are the
ones who say 'There but for the grace of God go I.' Each of these suicide attacks affects innumerable people
who, though anonymous, carry the scars, pain, anger and fear of the pigua for the rest of their lives. More of
us are included in that bull's eye than the outside world can ever imagine" (Sutta 2001).

For some bystanders the psychological wounds can be even more devastating than physical ones. "The
trauma of being an eye-witness to a lethal terrorist attack is mainly determined by the imposed passivity of
having to watch or listen helplessly to the sights and sounds of death and destruction" (Ayalon 2005).

The following three testimonies illustrate what really happens to bystanders when a suicide bombing takes place,
and defines in stark terms the trauma affecting these people, who are within the third ring of
wounding.

TESTIMONIES OF THE WOUNDED

"I saw body parts crashing through the broken car window"

On the
afternoon of 5 March 2003, F, a 74-year-old pensioner and retired
accountant, originally
from Russia, was a passenger in the car driven by her son on
Boulevard Moriah in Haifa. They were
waiting at the traffic lights, behind Egged bus number 37. Suddenly,
there was an immense explosion.
F recalls that she was unconscious for some minutes, then in shock.
"I saw parts of the bus and
body parts crashing through the broken car window." People came
to help her. Her face was covered
in blood.

Recalling that attack eight months later, F felt that the spirit of
her dead mother had helped to
save her. Her son had telephoned his wife who came to take Frida to
a nearby hospital. Frida was
wounded on the right side of her face, but was discharged the same
day because she did not want to
stay in hospital. She remembers after the bombing attack that she
felt fear, and had some panic
attacks. No volunteer organizations helped her, but a social worker
visited her at home in the
apartment where she lived. She consulted with her own local doctor,
which particularly helped her.
Eight months later the thoughts which helped her were hope for peace
and quiet for Israel. She still
feels some fear boarding public buses to travel to a nearby coastal
town because she remembers the
bombing. When she recalls the bomber who killed 17 people and
wounded 53 in that Haifa bombing
she says that they are 'ugly' and 'should not exist'. When she sees
another bombing on TV, she
remembers again that day of the bombing in Haifa and gets headaches
and some heart symptoms. She
says "Fear doesn't leave me, it is always with me."

Yoram, the
41-year-old father of three, had just closed his shoe store on the
Friday afternoon of 12
April 2002, after chatting over a cup of coffee with his brother and
a friend. He strolled up to the
Mahane Yehuda market to buy food for the Sabbath, including the
Yemenite pancake bread melawah
and strawberries. He was standing outside the market when he
remembered the meluwah. He headed
into a shop across the alleyway, about 20 metres from the bus stop.
As he stepped in, a tremendous
explosion rocked the market. Bodies were tossed about and blood
splashed everywhere. The suicide
bombing attack killed six people and wounded 66. Yoram grabbed a
roll of paper and rushed outside
to assist the wounded. The first thing he saw was a torso, severed
to the waist. That was as far as he
got. Crying, he rushed back into the store shivering.

Six weeks later, the once mirthful and talkative Yoram does not
watch TV or revisit the site of a
terrorist attack. He is a trauma victim. Images of severed arms, of
bodies sliced in half, of spurting
arteries, and pools of blood are indelibly etched in his mind. Every
time he closes his eyes, he sees
them, the screaming people, the chunks of flesh. When weeks later he
watched television images of yet another suicide bombing, he beat his legs, slammed his hand up
against his forehead, and slid his
Kippa (knitted head cap) over his face to shield himself from the
sirens and gore on his TV screen.
As TV images showed rescue teams hoisting bodies onto gurneys for
the ride to hospital in the wake
of the second Rishon Lezion bombing, he sobbed, began pacing and
weeping. He lighted cigarette
after cigarette. Tears rolled down his ashen face while his wife
feverishly tried to comfort him. Yoram
brought his hands up to his nose, smelled to check if the odor of
burning flesh was gone, then went to
the bathroom to wash them again. He could no longer eat meat. After
catching a whiff of the burning
hairs on a chicken wing at his brother-in-law's barbeque he fled the
party without saying goodbye.

"The smell was still there," he
said, "It choked me, it nauseated me. A prisoner in solitary
confinement
has more freedom than I do. I am in this house almost 24 hours a
day." He often cries himself into a
couple of hours' sleep at night, his sweaty palm clasped tightly
into that of his wife. Since the
bombing, he has lost 10 kilos in weight. He eats one meal a day,
better than the starvation that lasted
for the entire week after the attack. During that week, he ate and
drank almost nothing. He would
vomit up even the brittle edge of cracker. He was so weak that his
wife had to take him to the
emergency room to receive an infusion.

Danit stands listlessly, riveted over the spot where an hour before blood and vomit stained the tiles of
a shopping mall in Petach Tikva near Tel Aviv. Seconds after a suicide bomber detonated a bomb that
killed a woman and her granddaughter, Danit, standing with her five-year-old son at a video arcade
next door, sprinted to try to help. Bleeding bodies lay everywhere, as screaming women protected
shrieking babies. Danit scooped up one baby from a mother sprawled on the floor, and swaddled her
in her shirt, cooing to her and comforting her. Magen David Adom medics had rushed the lightly
wounded mother and her baby to hospital.

An hour later, Danit still remains at the spot, immobile.

Her husband had come to fetch her son and left. Her mother, also lightly wounded in the attack, was
in hospital with the rest of the family. Yet, Danit's legs refuse to bend, lift, or push forward, and take
her away from the site, now crawling with the media and curious by-standers. Her voice barely
audible, her face ashen and her lips almost blue, Danit manages to say, "I know I am probably in
shock, I will become myself again, but the problem is, how will I forget the babies crying, and the
women screaming 'Save me, save me!'" Danit, though battered by shock, is one of the lucky ones. She
knows she will recover, and staying at the scene is actually therapeutic. She begins to talk with
photojournalists about her experience, recounting the sights she saw earlier and how she feels. They
exchange stories, even manage a furtive smile.

It has been said that 70% of those who experience a terror attack may survive unscathed, like Danit, whose
natural and healthy mechanisms for denial and for the desire to soak up what she has seen and talk about it,
help her to recover. But, what of the 30% who cannot do this? What really happens to them?

JERUSALEM – CITY OF TRAUMA

Between September 2000 and February 2005, one hundred and sixty-six people have been killed in suicide bombings in Jerusalem and one thousand four hundred and eighty-nine wounded. The bombers have desecrated the holiness of the City of Jerusalem.

In 2002 trauma specialists estimated that 10% of all Jerusalemites suffered from Post Traumatic Stress
Disorder ((PTSD). This is more commonly known as 'shell shock' (World War Two term), or combat
fatigue. It is used to describe a myriad of symptoms of those who cannot return to normal life after
witnessing something terrible. Regardless of the term, the effect is the same incapacity to function normally,
breeding psychological devastation. Dr Danny Brom, Director of the Israel Center for the Treatment of
Psycho-trauma, estimated in 2002 that "thousands of Jerusalemites had been indirectly affected by the mass
destruction of terrorist attacks; they had trouble sleeping; suffered from nightmares; terrible anxiety; fear of
leaving home; light or severe depression; chronic headaches and flashbacks" (Gutman 2002).

He believed that much more effort was required to help them cope and augment their natural
mechanisms. Such efforts can be effective enough so that a great majority of those with psychological trauma do not need medical
attention or prolonged treatment. "Their minds slough off layers of pain, digesting what they can when they
can, slowly helping them ease back into normal life. That occurs in about 70-80% of instances of PTSD"
(Gutman 2002).

But some have difficulty switching on to this coping mechanism. The more 'experiential' the
trauma (like coming across a body severed in half) the harder it is to shake the trauma and return to normal
functioning. Often the victim may not understand his/her own survival of the attack. "The near miss reminds
us of our mortality, and then we can't live our reality. Our own very healthy denial mechanism breaks down.
But experience is not the only factor. Other stresses can contribute to a lingering sense of trauma, such as
prior poor health, difficult financial circumstances. Often it is the less affluent who are the main trauma
victims" (Gutman & Brom 2002).

In 2004, it was estimated that 40% of the population
in Jerusalem have some degree of Post Traumatic Stress Disorder

Over a decade ago psychologists looking at the effects of conflict in developing countries concluded that
psychological trauma may become evident in disturbed and antisocial behavior such as family conflict and aggression towards others. This situation is often exacerbated by the availability of weapons and by people
becoming inured to violence after long exposure to conflict. The impact of conflicts on mental health is,
however, extremely complex and unpredictable. It is influenced by a host of factors such as the nature of the
conflict, the kind of trauma and distress experienced, the cultural context, and the resources that individuals
and communities bring to bear on their situation. (Summerfield. D.I991)

In Israel, a Jerusalem Hospital Director reported in 2002 there had been more than 20 terror attacks within
500 metres of the hospital's doors. He estimated he had seen more than 1000 trauma victims, but considered
that there was little that could be done on the spot for them except to try and calm them with a sedative, and
'give them a lot of TLC' (tender, loving care) because most of them were psychologically healthy to begin
with. He reported that trauma symptoms varied greatly, with some people babbling on their cell phones,
others screaming and crying, and some self-flagellating. Later comes the fatigue, nightmares, chronic
headaches and constant flashbacks. Patients try to numb themselves to block the recurring images. Patients
sink deeper into shock that borders on being catatonic. This also affects their physical state from nausea to
poor sexual function. Some patients come with coping difficulties from two weeks to two years after an
attack (interview with Dr B, 2004).

THE EXPERIENCE OF NATAL

What is available for those who wish to seek help for the wounds to their minds and emotions? One prime
example is the Israel Trauma Center for Victims of Terror and War in Tel Aviv, better known as 'Natal'. It
not only operates a hotline for trauma victims seeking help, it tries to spread awareness about trauma victims
and educate the public about the mental wounds which can leave 'invisible' but deep scars. The following
interview illustrates the origin and expansion of Natal's work.

On the front-line in the war against trauma

In 1998 a psychiatrist, Yossi Adar, recognized that many psycho- emotional needs in Israeli society
were not being met by people suffering from conflict-related trauma. Among them were veterans of
Israel's many wars, even dating as far back as 1948. He recruited a team of professionals to create an
innovative approach to dealing with the wounds of the mind. Suddenly Yossi was taken ill with a
terminal illness, and died two weeks later. It was left to his dedicated staff to realize his vision.

Today, Natal, the Israel Trauma Centre for Victims of Terror and War, operates out of an office in a
converted house in south Tel Aviv donated by the Recanati family. It functions as a multidisclipinary
treatment center for victims of terror and war-related trauma, aiming to improve their quality of life.
It trains professionals and at-risk populations in preventing and coping with trauma. It furthers
knowledge and awareness about terror and war related trauma in Israeli society. In the first two and
a half years of Natal's work it received around 700 calls for help. Since the year 2000 ten thousand
people have sought the organization's help.

Natal operates a free 24-hour telephone hotline, a front
line in the war against trauma. The hotline is operated by non-professionals who have received a six-month training. They provide immediate emotional support to clients, and are supported by
professional counselors. Details are recorded only with the permission of the client. Some clients
want to enhance their link by visiting Natal personally. Some never appear, preferring to maintain a
regular telephone counseling link, even over a three year period, with the same volunteer. Calls are
reported to the Head of the Hotline, who decides if a personal meeting is desirable, or if the client
needs personal 'classic' or dynamic group psychotherapy. Some clients find it hard to establish that
first link. They may feel apprehensive, even fearing a degree of stigma because they need help. Some
even feel guilty that they need help, especially in a society where strength and resilience is highly
valued. Sometimes telephone counseling and 'staying with the line' can produce the motivation to
come in personally for therapy.

Natal also operates a therapeutic Social Rehabilitation Group, which is a meeting place for trauma
victims, and their families, who seek to meet others with whom they share a common experience.
Professional staff include experts in trauma and loss, who combine traditional verbal methods with
innovative non-verbal strategies such as movement and art therapy It is a supportive environment that
encourages social interaction for those who wish to improve their quality of life. Group members are
invited to 'coffee chats', lectures, trips, social interaction and confidence building sessions. The group
promotes non-verbal therapy through activities such as drawing and painting, body movements and
yoga. This therapeutic approach helps clients process their traumatic experiences and recreate their
sense of security and purpose. Each client is individually evaluated by senior staff that recommends a
personalized treatment program.

Many clients, who may range in age from 48 to 60, and who suffer some degree of post traumatic
stress disorder (PTSD), are not working. Many experience problems of finance, and problems within
their own social support systems. By bringing them in for group therapy they meet others with similar
experiences, re-learn some social skills, and discover new skills. One type of social group-work
involves learning cooking skills. Many clients neglect to feed themselves properly, perhaps living
alone, and not cooking often. Another activity involves painting on glass. Even those who deny having
artistic skills surprise themselves by producing colourful and expressive artwork. There is no analysis
of what is produced. The production process is the therapy.

Many factors influence the development and characteristics of conflict-related trauma in an
individual or community: for example, whether a person was actually inside a bus blown up by a
suicide bomber, or whether they saw it as a bystander; whether they sustained injury and how severe
it was; what they personally did at the time, such as whether they 'froze' in horror or rushed to help
wounded victims; what people around them did; what their family and friends did later; and, how
much help they received from professional sources.

Change can begin when a traumatized individual
recognizes what is happening to them and what happened to cause the trauma they are experiencing.
Natal staff and volunteers themselves can also experience 'secondary traumatization'- they feel
symptoms of trauma arising directly from the work they do with those who experienced trauma from
war and terror. Staff and volunteers meet regularly to share trauma-related experiences and coping
strategies. Individual counselling is available if they want it.

Natal's community staff has developed an ecological community-based program which has been
empirically shown to be effective. This program is currently offered through a variety of seminars,
workshops, lectures and conferences aimed at enhancing the ability to cope with emergency situations
and stress. These community activities target mental health professionals, rescue and emergency
service workers and high-risk populations. A Natal visitor (from Irish television) reported that around
3000 policemen in Ireland suffered some degree of PTSD due to the chronic nature of the conflict in
that society. Natal works with other Terror Victim Organizations, social services and social workers.
There is a 'Trauma Coalition Group', and links with municipally run trauma activities in various
parts of the country.

The traumas of war and terror are widespread, affecting individuals, families and societies. Their
effects are often instant, and also long-lasting. As one civilian survivor said, "Being a victim of
suicide bombing changes your whole life. Things are not as they used to be – in a negative way". For
the often-traumatized survivors of suicide bombings and other terror attacks, Natal is helping them
cope with their pain and suffering so that it can be more bearable, if it cannot be cured completely.

In Chapter Four the role of primary responders and front-line health staff was described. Doctors, nurses,
stretcher-bearers, nurses' aides, administrators, medics, primary responders, police, soldiers and even
journalists can suffer from the effects of trauma. Health staff are often inundated with a massive influx of casualties. As professionals they cope usually very well. But beyond the professional coping what are the hidden costs? Who is there to help the helpers ? A front-line nursing director of a Tel Aviv hospital
describes strategies for helping health staff cope better with the psycho-emotional effects of suicide
bombings.

"Sometimes we cannot sleep
because the smell of badly burned flesh will not leave us"

When through the doors of the Emergency Room (ER) a torrent of wounded civilians erupts, what do
health staff do; and what do they feel? A senior nursing administrator takes up the story: "We go into
automatic pilot, very rapidly. We do everything we have been trained to do professionally. The staff in
the ER opt to work there, and I even have a waiting list of nurses to work in ER. It is often the first
choice of our staff. Everybody in ER works well as a team. Nurses have trauma included in their BA
course. For four months a year, there is in-service training every four weeks for ER staff.

What is different about ER than other types of work, like working in a general ward, maternity ward,
outpatients clinic, is that we experience after a terror attack a massive influx of serious injuries. What
we see within a very short space of time is not the usual types of ER admissions. When suicide
bombings take place, we see people who are badly and extensively hurt, from blazing passenger
buses, destroyed cafes and discos. We see a mother with no hand. We see a man with his brain
exposed. We do our work as expected. But, at night we may dream of those sights. Sometimes we
cannot sleep because the smell of badly burned flesh will not leave us.

People outside the hospital, and people elsewhere in the world, do not understand what we see. We feel that as professionals our
job is to save people; if we cannot, we feel bad. After the last patients have gone, even that same
night, or maybe two days later, our staff, as many as 50 people at a time, sit down in our seminar
room with our social worker and psychologist. Staff are given an opportunity to express feelings and
to say what they feel. A safe place – where you can even cry. They have permission to feel bad, but
they will still be able to function. Our meeting gives legitimacy to their feelings and thoughts. Nobody
judges others. Staff may begin with the statement 'I feel bad'. Or, 'I felt my heart beating more quickly
than usual', or 'I have children - what will happen to them if this happens to me?' Or, 'I felt such deep
sympathy for the children who were carried in.'

The first time new staff are in ER when the torrent of patients arrive can be difficult. After that, you
think that you know; time makes some difference. If there is not a suicide bombing every day – as
there has been sometimes – we have time to forget and to heal ourselves a little. But the next bombing
makes the bad feelings re-emerge. We are sensitive; we care about our patients. Our seminar lasts as
long as people need it to, even 5-6 hours. At the end I look around into the eyes of all the staff. If
someone, maybe a male nurse, won't look at me, I say to him, 'Come and see me later in my office.' I
say 'How do you feel?' If they do not answer, I look in their eyes – and I can see they are still lost.
Then I say, 'Come and see me when you want'. They still need to be 'harnessed'.

You can't let the staff go home; maybe they will be alone, with no one to speak to them. You learn how to look into the eyes
of people. The suicide bombings will not break our spirit. Those who make the bombs and those who
send the bombers will not win. We will still be here. Peace for the people of Israel is not like peace
say between Holland and Belgium. Our peace will always be different."

Generally, medical professionals are surprised at the low rate of trauma experienced by hospital and rescue
workers. This may be partly due to 'professional detachment' which they must exercise while working at the
scene of the bombing. Keeping busy may help to prevent trauma. But the risk of trauma increases with
experience and can be cumulative. Yet, a 2002 article considered that symptoms of compassion fatigue (can
be) conceptualized not only as disruptive and deleterious effects of caring for the traumatized, but also as a
catalyst for positive change, transformation, maturation, and resiliency in the lives of these caregivers.
Specific suggestions for compassion fatigue prevention and resiliency are reviewed (Gentry 2002).

Post traumatic stress disorder, more commonly known as 'PTSD' can occur in a person who has been
exposed to a traumatic event in which they experienced, witnessed or were confronted with an event or
events which involved actual or threatened death or serious injury, or a threat to the physical integrity of self
or others. In addition, that person's response involved intense fear, helplessness or horror. In children, this
may be expressed instead by disorganized or agitated behaviour.

The traumatic event is persistently reexperienced in one or more of the following ways: recurrent or intrusive distressing recollections of the
event, including images, thoughts or perceptions (in young children, repetitive play may occur in which
themes or aspects of the trauma are expressed); recurrent distressing dreams of the event (in children, there
may be frightening dreams without recognizable content); acting or feeling as if the traumatic event were
recurring, including a sense of reliving the experience; illusions, hallucinations and dissociative flashback
episodes, including those which occur on awakening or when intoxicated (in young children, trauma-specific
reenactment may occur); intense psychological distress at exposure to internal or external cues which
symbolize or resemble an aspect of the traumatic event; and psychological reactivity on exposure to internal
or external cues that symbolize or resemble an aspect of the traumatic event.

What behaviour might indicate PTSD? Persistent avoidance of stimuli associated with the trauma and
numbing of general responsiveness (not present before the trauma) as indicated by three or more of the
following: efforts to avoid thoughts, feelings or conversations associated with the trauma; efforts to avoid
activities, places or people who arouse recollections of the trauma; inability to recall an important aspect of
the trauma; markedly diminished interest or participation in significant activities; feeling of detachment or
estrangement from others; restricted range of affection (e.g. inability to have loving feelings); sense of
foreshortened future (e.g. does not expect to have marriage, children or normal life span). In addition, there
may be persistent symptoms of increased arousal which were not present before the trauma, as indicated by
two or more of the following: difficulty falling or staying asleep; irritability or outbreaks of anger; difficulty
concentrating; hyper-vigilance; exaggerated startle response. In addition, PTSD may be present if the
symptoms described persist for more than a month, or if the disturbances cause clinically significant distress
or impairment in social, occupational or other important areas of functioning. PTSD may be considered
acute if duration of symptoms is less than three months, and chronic if it exceeds that. Also observed are
whether there has been a delay of onset of symptoms at least six months after the traumatic event.

Treatment for those suffering from PTSD can be achieved in 10-20 sessions with a professional. It consists
of three stages: The first is stabilization, in which the patient learns to regulate his physical arousal and
begins to conduct normal, day-to-day activities such as leaving home, or shopping. The next stage is
revisiting memories. This consists of visiting the site of the trauma either in memory, imagination, or in
reality, which the patient has avoided so meticulously. The third stage is integration, where the patient is
brought full circle into the daily activity or work engaged in before the traumatic event.

Traumatized by-standers may take a long time to seek help. The testimony below is of a woman who
survived a suicide bombing in 1996, but did not seek help from psychologists for the wounds of her mind.

I simmered until I boiled over –
earlier diagnosis of PTSD would have saved a lot of heartache

On 4 March 1996, crowds circulated in the Dizengoff Center shopping mall in downtown Tel Aviv. It
was two days before the religious festival of Purim, when children parade the streets in fancy dress
costumes. 'S', a mother with her two children and her parents, had been shopping in the mall. A male
Hamas suicide bomber from Khan Yunis in Gaza, wearing a coat to conceal his explosives, suddenly
exploded himself amid the crowds, killing thirteen civilians and wounding 100. The bomber had been
smuggled into Israel by Arab accomplices. The security guard at the mall had stopped him, so he had
blown up at the entrance.

Forty-four-year-old S recalls," We were going from the mall to meet my husband for a Purim outing.
We started to go downstairs towards the car parking area. Suddenly there was a huge explosion
which knocked me against a column. Dust started to fall from the ceiling. If the blast had been
seconds earlier we would all have been dead. We had just left an area encased in glass panels. My
father said 'Let's get out – the ceiling could collapse!' My mother stood immobile like stone. My
daughter Yael, aged five, stood in a daze. My daughter Dana, aged eleven, started to scream. People
emerged from the shattered mall covered with blood. The whole area was littered with broken glass.
The area looked like a war zone. My husband had been trying to contact us but our cell phones
weren't working.

I had gone into 'automatic'. I said to myself, 'We are going to get out of here'. I picked up my kids and
we all got into the car. I was worried about everyone else – except myself. For the next two days, I
worked like a robot. I had no feelings except for superhuman strength. I got my mother to see a
doctor, and my best friend came to help with our kids. I had bruises on my arm and my watch had
been shattered. I hadn't felt it break. My ears had been affected. I could not hear well for a long time.
When the media reported the extent and carnage of the bombing, I could hardly believe it. I
discovered that a colleague and her mother had been killed in the blast. I felt shocked. My mother had
a hard time after the bombing and needed tranquillizers. She had sleep disturbances and fits of
crying. My daughter Yael had total amnesia. Dana required therapy for two years. At first she
wouldn't sleep by herself. She used to hide, sometimes in a closet. She was anxious every time an
ambulance went by. She didn't like to go out much.

When I look back now I feel that the care I received at that time was wrong. I had often felt poorly
physically, occasionally with some jaundice. I had often felt nauseated with no appetite. When a bus
pulled up in the street, I would sweat. Everywhere I went I would first look for the exit. I felt my body
was going berserk. I was anxious, depressed, full of worries. I even lost a pregnancy. It took me a
long time to learn to let go before I felt better. I felt a lot of anger about what had happened to me. I
also felt guilty that I still had two legs and two arms, while other survivors had lost limbs.
But I still found it hard to cry and let myself go.

It took maybe three more years before I felt relaxed. I
still used to have panic attacks, with fast heartbeat, sweating, and feelings of faintness. I couldn't get
a hold of myself. I seemed to 'simmer until I boiled over'. Then I saw a couple of psychologists. My
husband is the son of a Holocaust survivor. He is strong. He used to say 'Everything is fine'. But I
wished someone had stepped in earlier to help me get therapy. No-one told me about any organization
that might have been able to help me. Not even my doctors. An earlier diagnosis of PTSD would have
saved me a lot of heartache. Nobody really knew how I felt – I hid it. Only a couple of close friends
knew.

Then came the Second Intifada. The thoughts which help me today are that I cannot control
everything. What has happened to me has reinforced my atheism. Unfortunately, I hate Purim. It
provokes too many memories – everybody in costumes. I associate Purim with blood. A tragedy can
tear your life apart like a piece of paper.

I feel now that I want to live. I have re-learned how to cry. A team of three health professionals
helped me to be able to cry. They helped me to regress almost to nursery school time. I was eventually
able to throw away my damaged watch from the time of the bombing. I found it is OK to be emotional.
What do I feel now about bombers and their families? I feel how dare they destroy my life and that of
other families. When I see on TV yet another suicide bombing, if I see children or young people
involved I turn to another channel. I feel anger and disgust, not anxiety. What helps me now is that I
do more volunteer work. I feel I can let go now and move on. You have to get past the anger to move
on. It took me 3-4 years before I felt happy, and could truly feel joy. Now I have almost come round
the circle to what I could feel before the Dizengoff bombing. I am determined to live a full life.

Sources: Interview with S, 18 June 2003

In December 1996, the same year as the Dizengoff Mall bombing in Tel Aviv, there was a terrorist attack on
a Paris subway in which 4 people died, 35 were seriously wounded and dozens affected by trauma. Medical
and psychological teams intervened immediately on the site to help victims (Jehel et al. 2001). A follow-up
study later indicated the importance of early diagnosis of PTSD to enable earlier medical and psychological
interventions for terror attack victims.

In the nineties Israeli experts in community stress prevention developed a multi-modal model to explain
mental resilience in stressful situations. The model 'BASIC Ph' relates to six major characteristics or
dimensions "at the core of an individual's coping style: beliefs and values (when a person copes by making
reference to self-reliance and his or her clear values, views and beliefs); affect and emotion (when a person
copes by seeking support in friendships, social settings and organizations); imagination (when a person
copes by acting according to his or her knowledge, thoughts and common sense; physiology and activities
(when a person copes by engaging in physical activity including eating, dancing and travelling). Each
individual has his or her primary combination of coping activities and resources, a style that reflects a
blending of all six dimensions" (Lahad & Cohen 1998).

How are Israeli civilians coping with frequent bereavements? Bereavement is about your life being changed
forever, about someone you care for dying, disappearing, not being there anymore. Sometimes expected
bereavement can be prepared for partially. If someone has an incurable condition there are many ways in
which they and their loved ones can prepare for bereavement. For example, a will can be made to ensure
possessions are left to particular individuals, groups, organizations. The dying unofficially will their
precious possessions to loved ones. The elderly grandmother gives pieces of jewelery to children and
grandchildren. The young man with an incurable illness wills his possessions to loved ones and friends.

But what of a sudden, unexpected bereavement which strikes like 'a thief in the night'? For this there are few
preparations. Like a scalpel, the bereavement incises the hearts, minds and emotions of the suddenly bereaved. Immediate responses to bereavement are usually moulded by whether the loss is personal or public.

Personal loss activates a range of responses, emotions and behavior which the person affected
displays publicly or privately. Public loss (i.e. other people's loss and grief- as in suicide bombings), activates
a range of responses and emotions and behavior which may be kept hidden, such as private weeping,
desperate prayer, struggle against grief, induced inertia, or may also be experienced publicly by attending
funerals of victims of suicide bombings. In Israel it is fairly common for people who do not know personally
the victim of a suicide bombing or their family to go to the funeral nevertheless to express sorrow and
solidarity, particularly if the bereaved are of a different ethnic group from their own. Israel is a small society.
The grief and loss of one family is often felt as the grief and loss of all. Personal grief is expressed by public
funeral attendance.

There are many patterns of public and personal grieving in Israel. Official memorial days link public and
private grieving processes. Yom Ha Zicharon (Day of Memorial for the Fallen) in Israel is a mix of public
and private grieving. In public there are evening memorial services, and public ones in the morning when a
siren sounds at 11 am and the country practically comes to a standstill. Vehicles stop, and a 3 minute silence
is observed in memory and respect of the fallen. But that same evening is the Eve of Independence Day
(celebrating the unlikely victory in 1948 when 40,000 Jews finally repulsed five invading Arab armies).
Concerts and celebrations take place publicly, preceding a day of private celebration
and barbeques. This timing 'curtails' the period of grieving for the fallen and celebrates the reality of survival and living, going
from death and loss and grief, to the hard won processes of survival and continuity.

But, for private grief the frenetic rush of daily living sometimes leaves civilians little time for prolonged
mourning and grieving. Attending to basic survival needs, such as having sufficient financial resources for
family food, payment of domestic bills, access to prescription medicines, occupy most of the thoughts and actions of the average Israeli family. In addition, family members may be serving full-time or part-time, or
as volunteers in the armed forces. Families face underlying anxieties for their very survival and welfare.

MYTHS ABOUT AND RESPONSES TO DEATH AND DYING

Death and dying are almost taboo subjects in many societies, even where they are daily occurrences. In
societies in conflict where death is a too frequent visitor, the chaos and grief of unexpected, sudden death is
almost always shocking.

The many myths about responses to death and dying do not help those affected when they are forced to deal
with the reality of death. When the knock on the door or the telephone call, or the media image confirms that
a loved one has died, the emotional pain and grief strikes deep wounds into the psycho-emotional make-up
of individuals and families.

What are the myths about responses to death and bereavement? An experienced thanatologist outlines some
main myths:

Dispelling some myths about death and dying

Myth

Reality

1. Time heals all wounds; it just takes time.

Time only passes – it doesn't heal unless you deal
with grief.

2. If you don't talk about it, it won't happen.

Death happens to everyone, whether you talk about
it or not.

3. It is for the best.

A comforter has no right to say this, although he/she
can say it about their personal loss.

4. Only the good die young.

No comment!

5. I cannot live without him/her.

Although this certainly feels very true, for the vast
majority it is not

6. A loss cannot be replaced.

All relationships are unique. No exceptions.

7. Children don't grieve.

Categorically untrue.

8. It's better not to see the body and remember
him/her as he/she was.

In the main, it is difficult to believe that a loved one
has died. It helps to have the additional visual and sometimes tactile evidence. Seeing has been shown
to help the grief to be processed.

9. Children should not go to funerals.

Children, as part of a family, have the right to
participate in family rituals. This participation
combats the child's feeling of isolation.

10. He/She needs time to be alone.

This is an individual thing. In the main, the problem
is more of isolation than of overcrowding.

11. It is important to be strong.

It is important to be allowed to break when the
support system is available, i.e., during the formal
mourning period.

12. Keep busy.

Being busy may be an excellent way of burying or
freezing grief, but NOT a good way of dealing with
and finishing it.

During the past four years, tens of thousands of Israeli civilians have been bereaved by the actions of suicide
bombers and their dispatchers. The following interview with a bereavement counselor illustrates some
characteristics of bereavement and grieving, realities which Israeli civilians have had to cope with as a cruel
legacy of the tsunami-like waves of suicide bombings over the past four years. The fact that the bombers
packed their explosives with shrapnel, screws and metal balls, meant that the remains of loved ones were
often gruesomely disfigured.

After a suicide bombing it is important to identify the body –
or what is left – of your loved one.

Bereavement is about being robbed or plundered, deprived, dispossessed, left destitute, at the death of a loved one. In the Netanya Park Hotel Passover Massacre on 27 March 2002, 30 civilians died and
140 were wounded, 20 seriously. A bereavement counsellor assisted two teenagers aged 18 and 15,
who lost not only their parents in that bombing, but had lost their grandparents three months earlier.
During a counselling session the boy asked questions not usually asked "You think I don't think they
are dead?" "Am I going to lose my mind?" "Is the kind of grief I am going through the worst I can go
through?"

Studies show the worst grieving is often that following the death of a child. You lose a lot
of things, but to lose a child is to lose the future. Sometimes parents feel, "I will never get over this."

Parents may also feel a sense of failure at having lost a child, in the sense that they could not protect
the child. Grieving sometimes involves a feeling of guilt on the part of those left, like the daughter
who had discreetly left a family celebration to have a secret smoke. While she was out a suicide
bomber detonated his explosives. When the daughter returned, it was to a scene of parents and family
massacred by a suicide bomber. It usually takes three months to realize that a loved one has really
died. If that person lived away from home, it may take longer. This means that the immediate support
system needs to remain in place for at least three months. Some studies have shown that bereaved
parents are often more efficient after their loss when they are at work, as a way of exercising some
kind of control. They 'hide' in their work. Sometimes people 'freeze' their grief.

There are three main issues when dealing with death; that death is a 'taboo 'subject (this can also
affect health staff); that it is unlucky to talk about death, even calling cancer 'the disease' rather than
calling it by name; that there are particular fears of death, such as in 'counter-transference' where,
for example, people meet a dying child and think the child may be 'the same age as my own child'.

Grief is slow; it may take one or two years to overcome grief. This time frame jars on the accustomed
speed involved in western lifestyles, where media images flicker across screens for 30 seconds, and
even meals can be prepared in three and a half minutes. With grief it is not acceptable to take 'shortcuts'. It is not like the 'instant Internet'. Grief takes time. It has a beginning, middle and end.

Bereavement counseling is 80% verbal and 20% body language. Grief may even get worse over a
five-year period. If people know it can be overcome, they have a better chance of doing so. Trauma
over death can also affect medical students when first dissecting bodies. Those who are actually doing
the dissection may not be as affected as those observing it. Western society marginalizes death. It
trivializes it, often using contrived and ghoulish media images.

After a suicide bombing it is important to identify the body, or what is left of your loved one. Parents
of one dead sixteen-year-old only had the arm left of their daughter. How do you help them to go and
look at it? You go with a colleague to see it yourself. Then you come back and carefully tell the
parents what you saw. Then you lead them gently into the room where they themselves can see with
their own eyes the arm of their daughter. Leave them alone for a few minutes. Alternatively, the dead
loved one may look curiously the same. For example, a young girl who sat next to a suicide bomber
on a bus died of explosive impact injuries (to her internal organs). When her parents saw her, her
face was almost untouched. Within several months the realization set in that their daughter was really
dead.

What is it like to lose several members of your family in a single suicide bombing? What are the processes
of grieving at the same time for several loved ones? Grief upon grief. For example, two families lost several
family members from single bombings in Hadera and Haifa. In each case the families were celebrating a
joyful meal. The first testimony is of a family celebrating a bar mitzvah when an al-Aqsa Martyrs' Brigades
suicide attacker entered the banquet hall.

"At first we thought the explosions were only fireworks"

The evening had been a joy-filled one, a bat mitzvah celebration for Nina, the granddaughter of A.
In the David's Palace banqueting rooms in the center of the coastal town of Hadera (near
Haifa), 180 guest were dining and dancing. At one table sat Russian-born Anna and her sister Rosa
with their husbands. The music was still playing at 10.45 pm as some guests were preparing to leave.
Suddenly, a suicide attacker, wearing an explosive belt, burst in hurling grenades and firing into the
crowded reception hall. Screaming guests fell to the floor in the hail of bullets and shrapnel. Six
guests died and 30 were wounded. Among the dead were Anatoly Bakshayev (63), Rosa's husband,
and Anna's husband, Edward (48). An evening of celebration had been turned into an
evening of tragedy.

The suicide attack had taken place on 17 January 2002. Nearly two years later A recalls, "We
were sitting at our table enjoying the Bat Mitzvah. My husband took our son home because he didn't
feel well. He returned. People were dancing, drinking, and joking. Suddenly, we heard shooting. At
first we thought it was fireworks. "A couple of minutes earlier Rosa's sister A had left her
husband's side. When she came back after the shooting she saw her husband lying on the floor in a
pool of blood.

Anna recalls, "People were crying, there was chaos. I felt shock. Immediately after the
first killings guests tried to overpower the terrorist. His eyes were staring, maybe from drugs. Guests
threw bottles, and ice, at him, kicked him, used anything they could. They killed the terrorist to
prevent him from killing more people. He still had half his bullets left and one of his three grenades.
The guests were really heroic."

Rosa recalled that other guests had helped her a lot at the time. However, the police seemed to take a
long time to arrive. Rosa's husband was taken to nearby hospital, but he died on the way. Anna
remembers, "My husband danced with me only once that evening. Mostly he sat at the table, with his
back to the entrance of the hall. That day he had behaved a little strangely. Usually he used his credit
card at the market, but that day he had paid everybody."

Immediately after the attack, people visited Rosa and Anna, including a Government Minister, and the
local mayor. The factory where Rosa worked stopped work for a day after the tragedy. Eventually
Anna started to draw comfort from Kabbala (Jewish mysticism). After the suicide attack several terror
victim organizations tried to help the two sisters and their grieving families. But, overall, the sisters
did not feel that it helped very much. They also consulted a psychologist but felt that did not help
either. Afterwards, they recalled, they had felt very nervous.

Rosa says, "Today I draw comfort from my grandsons. My husband dreamed about our daughter
getting her own apartment. On the anniversary of his birthday my daughter and I went to visit his
grave to wish him 'Happy Birthday'. On the way home we saw an announcement about the sale of an
apartment. My daughter bought that apartment on my husband's birthday. The local mayor has
erected a monument to our dead husbands in the centre of Or Akiva where we live."

Sadly, tragedy continued when a year after the suicide attack killed his father, Anna's twenty-year-old
son committed suicide. He had been very close to his father. The loss of the two husbands on a single
night was a terrible blow. Rosa misses her husband, who liked to joke and dance, and constructed
wooden kitchen cabinets as a hobby. When she sees another suicide bombing she feels very bad. "I
turn off the TV," she says, "I would like to see more peace and quiet and less evil. People outside
Israel should know what is really going on here."

Anna and Rosa both want to move on to conquer their grief and to continue their lives. They sit, the
pain and grief still etched on their faces, surrounded by photo albums and pictures of their husbands
and of the Bat Mitzvah celebrations on that fateful night two years ago.

Source: Interview with Rosa and Anna , Or Akiva 10 November 2004

The next testimony is of a family who lost five family members in a single suicide bombing. Near Haifa, on
Saturday 4 October 2003 an extended family was enjoying a mid-day meal in the popular Maxim Restaurant
by the sea. What happened next and the consequences for that family are almost beyond imagining.

"In one second three generations of our family were murdered.
For our family it was a Holocaust in Israel"

Just after 2 pm on Saturday 4 October 2003, a plane landed at Ben Gurion airport bearing Program
Manager Ofer and his boss, returning after a business trip to Brazil. As they waited to collect
their luggage Ofer's boss made a call on his cell-phone. He turned to Ofer and said "There has been a
suicide bombing in Haifa ". Ofer recalls, "Every time I land after a business trip, I call my wife Galit
in Haifa to say I am back. That afternoon I tried to call her from the airport, but no one answered. At
first I didn't think my family had been in the bombing. But after nobody answered their cell-phones, I
thought maybe they had been. Our son Omri knew that the family had all been in the Maxim
restaurant that day. As I was driving to Haifa, he called me to say he had called all the hospitals in
Haifa, and found out that only three of our family had been admitted to hospital. Then I got a call
from a woman who told me my wife was in hospital. I didn't know where my other family members
were. It was a very hard time.

When I arrived at the Rambam hospital in Haifa they told me that, except for my sister-in-law and her
two children, other family members were not there. I said, "I know that my wife IS here ". The woman
who had called me earlier said she had seen my wife and that she had given her my cellphone
number. I searched for Galit for more than two hours. By this time my parents were at the hospital
with me. Then we heard that Galit was in surgery, badly wounded. It was about 6.15 pm, just four and
a half hours since I had landed at the airport.

I realized that it would be some hours before I could see Galit. In order to find the rest of our family I
also knew I would have to go to the Forensic Institute at Abu Kabir near Tel Aviv. Leaving my parents
at the hospital, I set out in a taxi for the almost two-hour drive southwards. When I arrived, Professor
Hiss met me. He told me he could not immediately show me my family members who had been killed.
They were not yet ready for me to see. He was wonderful to me. He took blood to use in DNA testing
to see if a young boy brought in after the bombing at Maxims was my ten-and-a-half-year-old son
Asaf.

I returned to Haifa and went to our eldest son fourteen-year-old Omri. We walked in the street
together, and after we talked we both cried. He said, "I want to stay with a friend." I returned to the
Rambam hospital at 3 am, after not sleeping for 24 hours. I didn't feel tired. I didn't feel anything.
When I first saw my wife at 3 am in the middle of that night, her head was covered with dressings. The
shrapnel had made a hole in her cheek. I could see her tongue through the hole. She had instruments
in her mouth. It was terrible to see her. She couldn't talk, couldn't see, couldn't move, couldn't feel
when we touched her. After three days, she began to understand what had happened. The doctors in
Intensive Care stayed with us all the time, from Saturday to Tuesday. I talked a lot with them,
especially about how to be able to tell the story of what had happened to our family. Then the doctors
told me that Galit was paralyzed – and I fainted. Galit had upper spinal cord injury, wounding of the
right hand which had affected the nerves, a broken left arm, shrapnel and metal ball injuries all over
her face and upper body. (The shrapnel injuries to her eyes destroyed her vision for a month). At five
thirty Professor H phoned me to say it was our son Asaf in the morgue."

Galit recalls, "The day of the bombing my husband was flying back from a business trip to
Brazil. lt
was a sunny day, so I took my younger son Asaf at midday to the beach to meet my parents and my
brother Moshe his wife Orly, their children and my mother's cousin. We were a big family group.
Someone suggested we go to the Maxim beach-side restaurant for lunch. We sat down to eat. I was
talking to my sister in-low. Suddenly, I could not hear anything. It was as silent as death. I couldn't
see anything. I didn't understand what was going on. I thought 'Why do I have such a headache?' I
drifted in and out of consciousness. I was screaming 'Help me'!' People came to help me and put a
tube down my throat. I told those people that my husband was landing at the airport at that time, and
gave them his cell-phone number. They said they were going to take me to hospital. I remember being
taken into the ambulance. As I was unconscious on arrival nobody in the hospital knew my name, so I
was listed as 'anonymous.

I remembered seeing the suicide bomber standing between my father and my brother in the
restaurant. She had looked like a young Israeli women, and she was very pregnant. I remember
thinking 'What is she doing standing between my father and my brother?' When the restaurant
exploded I didn't think anything, but I knew members of my family were dead. Later, I remember Ofer
asked me 'Do you know what happened?" I said "They are all dead except my niece (five-year-old)
Adi and my husband." Then Ofer told me that Adi had survived, and her mother Orly, and her son ten-
year-old Oran (who was totally blinded by the bombing). But, I knew my parents were dead: my
charismatic father, seventy-one-year-old Z. A, retired naval officer and submarine captain;
my 'super-mother', seventy-year-old Ruth; my brother, forty-three-year-old Moshe, who worked in
marketing medical equipment, and his nine-year-old son, the cute and ever-energetic Tomer. Above
all, I knew that we had lost our youngest son, ten-and-a-half-year-old Asaf, a warm and beloved child
who had loved everyone, and who was very good at sports.

After two and a half weeks in hospital I was transferred to the Rehabilitation Unit in Tel Hashomer
hospital in Tel Aviv, where I stayed for eleven months. My most frequent thoughts after the bombing
were that I needed to concentrate on my remaining family, and on personal survival, and on living.
But this was like talking from the head, not the heart. I couldn't mourn and I couldn't cry. I felt
immense pain and sadness. For us the attack had been like a 'Holocaust'. In one second three
generations of our family were murdered. I didn't know who to think about first. I thought of our
surviving son Omri and his losses. We tell our children in Israel that the Shoah will not happen again,
but for our family, it did happen. This was not Germany or Poland, but Israel. We cannot teach our
children Israel is a safe place for Jews.

My husband has stayed most of the time with me. He took a year off work. At the beginning I couldn 't
move at all. I had to be fed and bathed. I was not used to being helpless and I needed a lot of
patience. The hardest thing was not being able to be with our son Omri. Our close-knit family was
split. Ofer stayed near the hospital where I was in Tel Aviv. But, our son Omri was in Haifa. It was
eight months before I got back to my own home for weekends. But then we had to move from there
because I could not manage the stairs. Now we live in a rented apartment with no stairs.

We were helped a lot after the bombing by our close family, and by friends and work colleagues.
Friends took it in turn to sleep near me in hospital at one period. At first we did not consult
Psychologists. Now I am doing some art and making ceramics, and talking weekly with a
psychologist. We were helped by the Terror Victims organization One Family who have visited us
every week. We are not in contact with other terror victim families and do not belong to a support
group. I prefer to sit with people who have not been through what we have experienced. If there was a
God and He had mercy such things would not happen. Even at the funeral of our son we didn't want
mention of the mercy of God. The Jewish Reform movement has helped us a lot, over our son's
funeral, with supportive contact, and with thousands of e-mails from many countries. Basically we
have been able to receive the state and health benefits which we have needed."

Galit has been at home now for three months. She says "What helps me most today is doing what I
can for our son Omri. He has recently done very well at his exams and sports. Only now, fifteen
months after the bombing, we are getting back to being a family. But it is frustrating for me to need so
much help and to have to recognize my disabilities. The hardest thing is weekends or holiday times,
when I realize my whole family is not here any more. I feel sad and miss them so much."
Neither Galit nor Ofer think about the female bomber who slaughtered their family. They say, "She
was a monster. All bombers are monsters wanting to kill us. I cannot describe them as human as they
are destroyers of people, of babies. When there is another suicide bombing on TV we watch a bit to
know what is going on, then we turn off the TV". Galit says, "I cannot look at those kinds of pictures
again. Before the Maxim bombing I could watch a bombing for an hour and feel pity for people. I
don't need that. I know exactly what happens in a suicide bombing"

It has been said, "the Israeli formula for dealing with terrorism has been a combination of stoicism, memory
and fighting back" (B. Stephens, 2002). But, for families coping with multiple bereavements, the challenges
are complex and the 'triggers' which activate painful memories more plentiful.

International trauma training, meaning the training in mental health and psychosocial interventions for
trauma-exposed populations in clinics and community settings occurs when professionals with expertise in trauma and mental health travel from one international locale to another to train local practitioners to
respond optimally to trauma-related problems. Several international organizations have moved in the
direction of developing standards for strategies and practice for international mental health and trauma
training. In this new field, guidelines facilitate the process by providing principles and strategies. Training guidelines include ethics of training, training of primary care workers, training and self-care, and training under, and following, a terrorist siege. Sometimes trainers can find themselves ill-prepared. (Maynard 1999,
Walker and Walter 2000).

For example, humanitarian aid efforts in Kosovo were criticized for lack of
prioritization, coordination, standards and professionalism (Perlez 2000). During the 1990s the international
trauma mental health movement had come to the Balkans in the form of 'trauma training'. Traumatic stress
and mental health knowledge were applied widely and enthusiastically, but the outcomes were not always
beneficial, and in many cases may have been hurtful (Maynard 1999). The 2000 Red Cross's World Disaster
Report sharply criticized international mental health initiatives and issued an urgent call for better standards
to better design relief efforts.

Trauma, bereavement, multiple family losses – sadly, these are not the singular experience of Israel. Many
countries around the world acknowledge the need for increased assistance to trauma-exposed populations. A
Task Force on International Trauma Training of the International Society for Traumatic Stress Studies has
been established, with 2000 members in at least 40 countries. The task force believes that training in mental
health and psychosocial interventions requires an integrative approach across disciplines and sectors, and
includes disciplines such as anthropology, economics, international development studies, law, philosophy,
political science, psychiatry, psychology, religious studies and sociology. The task force set about producing
guidelines, engaging in a one-year dialogue on the practice of international training, drawing on field
experience, literature review, and consultation with key informants.

In 2002 a task force set out guidelines for international training in mental health and psycho-trauma.
Training has to be "culturally sensitive and appropriate, and indigenous concepts of mental health and
healing have to be understood, as well as indigenous ways of approaching human suffering. Also, ways to appropriately enter complex environments in conditions that may be insecure. "Trauma training in societies
during or after conflict takes place within a complex social and political context in which multiple sectors
and stakeholders seek a voice in shaping the reconstruction process... The potential for tension, friction and
even overt conflict may continue after a ceasefire. Locating the sources of power, decision-making, priority
setting, and planning may be difficult because authority may shift from one leadership structure to another...
Psychosocial interventions may only be effective as a public health strategy if these activities support and, in
turn, are supported by progress in re-establishing the fundamentals of a stable social environment. Repair of
the social environment involves re-establishing the structures, institutions and cultural framework that
moderate the impact of mass threats, losses and injustices" (Weine et al. 2002).

Israel has mental health professionals and paraprofessionals who provide mental health services, unlike
many low-income countries where such services may still be provided by health care professionals and
paraprofessionals. In trauma care in low-income countries, potential trainees can be found in the education
sector, among human rights groups, police, and clergy. Training includes competence in listening and other
communication skills. Trauma training is envisaged as including treatment of stressor-induced symptoms or
distress, but also covering approaches to reducing problem situations whenever possible, on an individual,
family or community level. Psychosocial services also need to be linked to medical services, to address
medical needs, such as unexplained psychosomatic pain.

"Local human resources such as clergy, teachers, traditional healers, formal and informal leaders, may help
trainers and trainees understand indigenous perceptions of suffering, illness, pain and healing. (Such leaders
may also play an important part in building or rebuilding social support networks.) Paraprofessionals are
likely to master most interventions if these are socially and culturally appropriate and if they receive
sufficient supervision. However, to train in an area without setting up a structure of ongoing supervision and
support is unlikely to be sustainable and may lead to harm... Self-care and encouragement of support among
trainees is essential (because) previous traumatization may limit the trainee's effectiveness, (and) caring for
severely traumatized people may lead to vicarious traumatization or other forms of burnout" (Weine et al.
2002). Useful methods for training include combining qualitative and quantitative methods, including
surveys, individual interviews, focus groups, and participant observation.

In 1992 Israeli trauma experts were approached to help in the former Yugoslavia to assist its struggling
mental health professionals.

The seminar began with much animosity, if not expressed hatred.

When mental health professionals themselves become victims of trauma, especially secondary to a
war situation, it becomes the ultimate test for fellow professionals. Now they are put in the position of
supporting and helping those who provide assistance to others. It brings to the surface one's own
uncertainties, fears and vulnerabilities. Whatever the specific character of any particular war, it
always involves destruction, pain, loss and death. But while the physical loss can be reconstructed or
replaced and the pain and sorrow may gradually diminish, it is the psychological scars, the trauma,
the horrifying images and memories that do not heal for many years.

In Israel, one meets such people
in the form of Holocaust survivors of more than 50 years ago, who till this day, relive their trauma
and frequently transmit it to the second and third generations. (Some elderly women who were
Holocaust survivors cannot even today bear to see piles of hair on the floor of a hairdresser.)

Israel's unenviable experience of multi-generational trauma was put to good use in the summer of
1992 when a plea for help was received from a Muslim leader in the former Yugoslavia. At that time
Israel was in the middle of its struggles with the first Palestinian Intifada. Riots and casualties were
daily occurrences. The mental health professionals were desperately searching for ways to cease the
violence and prompt peaceful negotiations between the Palestinians and Israelis.

Therefore it was somewhat ironic to receive this plea for help from a Muslim leader in a country which no longer
existed – Yugoslavia. "After visiting the areas, it was quickly learned that the psychological damage
far exceeded the extensive physical damage. There were hundreds of children completely traumatized
and adults whom the war had drastically dehumanized. Worst of all was to see the 'helpers' –
physicians, psychologists, teachers and social workers – who were completely exhausted, frustrated,
disoriented, and unsupported. Some were on the verge of breaking down and burnout. It was difficult
to witness caregivers who themselves had no one to take care of them, and sadly they were unable to
do it themselves.

In addition it was not easy to escape the religious and ethnic hatred between groups.
This was a deep and dark hatred fueled not only by atrocities in this war, but based on far-reaching
historical memories that had long been suppressed, only to surface and be manipulated by those in
authority and in power. Hence these two sources, immediate and remote, together created a toxic
memory that was poisonous and destructive for human interrelationships.

It became clear also that in order to save and help high-risk populations, i.e. children, refugees, girls
and women who had been raped, it was more important and imperative to first help the professional
helpers who were providing assistance. As it would have been hard to teach recovery methods under
constant bombardment, shelling and sniper attacks, with UNICEF assistance, two-week programs
were developed in Israel, with seminars, intensive training in various trauma relief issues, de-briefing
sessions, and dealing with individual stress and burn-out. It allowed participants to recharge their
batteries, and to develop realistic goals of what they could accomplish when they went back to work
with a population that was at risk and more directly affected by the war."

The first workshops were designed for mental health professionals who had been compelled to take on
the almost impossible mission of providing non-stop treatment for war-affected and traumatized
children and adolescents. Chronic post traumatic stress disorder and other forms of mental disorders
such as depression and anxiety, may be observed among one-fourth to one-third of individuals
exposed to unusually stressful situations such as disasters, acts of violence and various war-induced
stresses. Each workshop contained participants from each of the adversarial groups.

A year and a half later, representatives of these same groups were involved in a joint workshop. Participants
included psychiatrists, psychologists, teachers, university professors, sociologists, and librarians.
Graduates then conducted workshops when they went back to Yugoslavia. To date, this model has
become the standard training method of mental health professionals in the former Yugoslavia. The
theoretical basis for the workshops was predominantly derived from the Community-Oriented
Prevention Education (COPE) model as designed and described by Dr Ofra Ayalon in 1987. This
model is primarily geared to help children and adolescents to promote coping skills in order to deal
with stressful events of everyday life, and also with emergencies caused by the disruption of social
equilibrium and security. The basic premises in this approach are that distress caused by death,
separation, threat to health, pain and loneliness can be mitigated. The goal of the workshops was not
only acquisition of skills, but also promotion of professional self-assurance. From a state of extreme
exhaustion and a sense of helplessness, the hope was to re-charge the 'batteries' of the trainees and to revive their sense of self-efficacy, competence and professional pride.

The main components of the program included theoretical and conceptual inputs related to stress and
trauma, children of families who have been traumatized, expressive methods including
'bibliotherapy',
story-telling, puppetry, video therapy, an and music therapy. Small-group work was used to enable
trainees to plan a project that would eventually be applied in their own workplace and/or community.
Over the two-week period a very poignant group dynamic evolved. From a group of professionals
who had come from different, separate, perhaps even hostile, regions of the former Yugoslavia, with
each individual containing his/her own diverse expectations and mixed emotions, developed a
'learning organization' (as one participant chose to call it) with a blossoming motivation to absorb as
much as possible for application back home. In conjunction with the enhancement of their individual
awareness, the group members learned to overcome inner conflicts, strengthening their self-
confidence, and drawing upon the enrichment of their previous knowledge and skills, hence instilling
in them a sense of expertise in their exhausting mission. The evaluation conducted at the end of each
workshop yielded very high appraisals.

Follow-up later revealed that graduates had also been
involved in conducting local seminars and training workshops with professionals from various
disciplines, such as school psychologists, teachers, mental health specialists.

In 1995 a combined training seminar for members of all parties in the former Yugoslavia resulted in
an 'Integrative 'seminar in neutral territory in Visegrad, Hungary. The seminar revealed the critical
significance of the identity crisis generated in a situation such as the one in the former Yugoslavia.
The identity confusion stemmed not only from the disintegration of one's former nation, but also from
the disillusionment of assumed moral integrity. While the 'Integrative 'seminar began with much
animosity – if not expressed hatred – between the different adversarial groups (i.e. Bosnians, Croats
and Serbs) it gradually evolved through initial dialogues into an interactive and subsequently
mutually supported professional network.

What became rather apparent , but puzzling, during this
seminar were those frequent vacillations which occurred among the trainees. At one moment they
would behave in a strictly professional and non-partisan manner, and moments later, they would
expose their ethnic or national identity, breaking down into adversarial factions. This led to the
realization of how policies influence people differently, and that historical animosities between
groups do not necessarily diminish automatically with evolving affection among individuals belonging
to these groups. However, even an enforced dialogue may start a process of de-mythologizing the
enemy and projecting one's own hatred and rage, a process that eventually may lead to reconciliation
between former adversaries. Individuals who are victims of disastrous situations respond first and
foremost as human beings, regardless of their religious, ethnic or cultural background and
differences.

Early in the Second Intifada, an Israeli psychologist reported, "People are walking around today with eyes glazed over with shock, disbelief and anger and incredible sadness. It hurts more because city centres that
we are all familiar with are attacked and targets are children and young people" (Dr Batya Ludman, psychologist). "The goal of terror is to sow fear and disrupt normal life...the killing is only a means to that
end... Terrorism strives to instil a feeling of constant uncertainty and strip you of control over your life...Israelis have a high threshold for coping with traumatic events... They reduce their expectations in order to come to terms (with a difficult situation)... Decades of war have already had an impact on Israeli children who, according to one landmark study, have a sense of their own mortality by the age of five. In other countries the average age is nine years" (Mooli Lahad in Eren Frucht 2002).

Two years later psychologists continue to analyze how civilians continue to respond to suicide and terror
attacks, which have been described as the 'plague of the twenty-first century'. Can there be immunization against trauma and terror? An Israeli civilian confided, "This conflict scars minds, emotions and souls, on both sides of the conflict. You rarely cry during war – it would be a luxury. But, sometimes the silent 'tears'
slide down secretly inside you when something particularly gruesome happens, like the two soldiers lynched
in Ramallah, their falling, bruised bodies slit open at the abdomen, then dragged, still apparently alive, along
the street.

Or the Israeli TV pictures (but hidden by the global media) of the massive pile of bloodied stones
used to torture and kill two lost Israeli schoolboys in a dark cave near Bethlehem.

Or the face of Shalhevet, the ten-month-old baby whose father's cradling arms must have frozen in disbelief as a terrorist's bullet
pierced her head.

Or the woman in Jerusalem who picked herself up after the Mea Shearim suicide bombing
shouting in agony 'Where's my arm? Where's my baby?' Her severed right arm lay on the ground not far
from where her screaming baby was burning to death in its stroller.

These are the events and images we live
with day after day, week after week, new ones crowding out the older ones, because they are all 'stored on
the hard disc' of our existence, and there is no 'software' that can ever remove them. These are the scars on
our landscape, and we have to live with them."